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房颤消融技术新进展: 标测与消融技术

房颤消融技术新进展: 标测与消融技术. 广东省人民医院 广东省心血管病研究所 詹贤章. 房颤、房速标测新方法 ---- 房颤转子 (Rotors) 的标测与消融 ---- 高密度标测技术 消融能源、器械、设备等新进展 ---- 房颤冷冻球囊消融技术 ---- 压力导管在房颤导管消融 中 的临床应用 ---- MediGuide 技术. 房颤消融技术新进展: 标测与消融技术. 房颤消融技术新进展: 标测与消融技术. 房颤转子 (Rotors) 的标测与消融. 房颤转子 (Rotors) 消融. 房颤转子消融.

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房颤消融技术新进展: 标测与消融技术

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  1. 房颤消融技术新进展:标测与消融技术 广东省人民医院 广东省心血管病研究所 詹贤章

  2. 房颤、房速标测新方法 ----房颤转子(Rotors)的标测与消融 ----高密度标测技术 消融能源、器械、设备等新进展 ----房颤冷冻球囊消融技术 ----压力导管在房颤导管消融中的临床应用 ---- MediGuide技术 房颤消融技术新进展:标测与消融技术

  3. 房颤消融技术新进展:标测与消融技术 房颤转子(Rotors)的标测与消融

  4. 房颤转子(Rotors)消融

  5. 房颤转子消融 2012年11月美国加州大学医学中心的Narayan医师等发表于JACC的研究结果引起了各国电生理医师的注意; 该中心开创性地使用了一种新型的电标测系统来指导AF消融; 该系统将2个64极网篮电极放置在左右心房,对自发或诱发的AF进行多点同步标测,而系统自带的软件可以自动分析标测记录的电位,找到AF维持的基础即“快速放射状传导的局灶电激动”或快速折返的“局部转子”(focal impulse and rotor modulation,FIRM)

  6. CONFIRM试验 Narayan等入选了92例症状性AF患者(持续性AF患者占72%),他们共接受107次连续的消融术。(FIRM消融组,n=36)及单纯传统消融组(n=71)。97%的患者存在AF转子(70%)和局灶激动(30%) Narayan SM, et al. JACC, 2012, 60(7):628-636

  7. 局灶激动和AF转子联合传统消融可获得更高成功率局灶激动和AF转子联合传统消融可获得更高成功率 FIRM消融组术中86%患者AF终止或心室率减慢,而传统消融组仅为20% 单次消融后平均随访273天,FIRM联合传统消融组的SR维持率远高于传统消融组(82.4% 对 44.9%) Narayan SM, et al. JACC, 2012, 60(7):628-636

  8. CONFIRM组AF起源点分布图(转子和局灶激动) 持续性AF 阵发性AF Narayan SM, et al. J ACC, 2013, 62(2): 138-147

  9. 左房下部房颤转子 左房前壁房颤转子 Narayan SM, et al. J ACC, 2013, 62(2): 138-147

  10. 转子消融的优缺点 为持续性AF患者导管消融提供了新的治疗策略,它首次将AF的病理生理机制作为消融靶目标 其它电生理中心未能重复证实 并非随机对照研究 针对转子或局灶激动的消融可能只是PVI的“锦上添花”,而PVI仍是AF导管消融的基石

  11. 房颤消融技术新进展:标测与消融技术 高密度标测技术

  12. EnSite Velocity系统指导下高密度标测

  13. 詹贤章,薛玉梅,吴书林等. 中华心律失常学杂志,2012,16(6):424-430

  14. High-Resolution Mapping Catheter (Mini-Basket) 64 Low Noise Electrodes Electrode Area 0.4 mm2 2.5 mm center-to-center Magnetic & Impedance Location Sensors 8 Fr Bidirectional Catheter 18 mm Variable Deployment Diameter (3 – 18 mm) 8 Splines Rhythmia Medical, Inc

  15. Canine RA Activation Map During Sinus Rhythm Average Mapping Resolution 2.3mm SVC Activation Time 31 ms RAA RAA Earliest Atrial Activation -58 -68ms Tricuspid Annulus Tricuspid Annulus - Scar No Potential IVC Mapping Time: 8.2 min Electrograms: 8,227 RL Projection LL Projection

  16. RA Activation Map During Sinus Rhythm (Pre-Surgery) 10 / 8,227 (0.1%) points were manually annotated SVC Activation Time 31 ms Earliest Atrial Activation -58 -68ms Tricuspid Annulus Tricuspid Annulus - Scar No Potential Mapping Time: 8.2 min Electrograms: 8,227 IVC RL Projection LL Projection

  17. RA Activation Map After 2 RF Linear Lesions SVC Pacing Posterior to RF Lesions Posterior Pacing Site RF Lesion RAA Mapping Time: 9.3 min Electrograms: 4,069 Manual Annotation: 10/4069 (0.2%) Points Map Resolution: 2.5 mm AV TA Gap Gap 105 ms 103 Anterior Pacing Site RF Lesion IVC 11 6 ms

  18. Roving Prove at Gap RL Projection SVC V4 CSp CSd S Bip 1-2 Roving Probe Map 105 ms 103 Uni 1 Tricuspid Annulus Uni 1 dV/dt 11 6 ms Uni 2 IVC

  19. RA Activation Map After Endocardial Ablation of Gap Mapping Time: 4.7 min Electrograms: 2,926 Manual Annotation: 10/2926 (0.3%) Points Map Resolution: 2.8 mm Ablation 105 ms 103 Pacing Posterior to RF Lesions 11 6 ms

  20. RA Activation Map After Endocardial Ablation of Gap Mapping Time: 4.7 min Electrograms: 2,926 Manual Annotation: 10/2926 (0.3%) Points Map Resolution: 2.8 mm Ablation Pattern of Activation Continuous Lineof Conduction Block 105 ms 103 Pacing Posterior to RF Lesions 11 6 ms

  21. Rapid, Automated, High-Resolution Electroanatomical Map • Electroanatomical Map • Based on all electrograms recordedwithin a selected distance (1 - 5 mm) of the surface geometry • - 2 mm distance used for this study • Activation, voltage and FAP maps are generated automatically • Electrograms at any site can be reviewed quickly to verify or re-annotate (Dynamic Review)

  22. Rapid, Automated, High-Resolution Electroanatomical Map Fractionated Atrial Potential (FAP) Algorithm • Counts number of activations in 2.5 sec window, • calculates mean cycle length (CL) • Activation Detection • - Bipolar electrogram • (electrode 0.40mm2, 2. 5 mm spacing, center-to-center) • - Minimum threshold 0.035 mV • - Minimum interval between activations 30 ms

  23. 50 1000 70ms Ablation at FAP Areas 70 yr M, Persist AF Prior AF ablation X 3 (PVI and CFAE) V6 AP Projection CS FAP Bip1-2 Mean CL 66 ms/2.5sec Uni 1 100 ms Uni 2

  24. 70 yr M, Persist AF Prior AF ablation X 3 (PVI and CFAE) 50 1000 70ms Ablation at FAP Areas V6 AP Projection CS FAP Bip1-2 Mean CL 66 ms/2.5sec Uni 1 Ablation Terminated AF 100 ms Uni 2

  25. CONCLUSIONS  The small, close bipolar electrodes and very high density of mapped sites with this new mapping system allows rapid localization of fractionated atrial potentials (FAP) with very high resolution in a canine model and AF patients  Localization of FAP is less accurate using a conventional mapping/ablation catheter (3.5 mm tip electrode, 4mm inter-electrode spacing, center-to-center) with point-by-point acquisition due to both lower density of mapped sites and lower recording resolution

  26. Individual AF characterisation via non-Invasive Mapping from surface ECG

  27. Cavotricuspid dependent AT Shah A J,et al. JACC, 2013

  28. Perimitral AT Shah A J,et al. JACC, 2013

  29. Roof dependent AT Shah A J,et al. JACC, 2013

  30. Left atrial focal AT Shah A J,et al. JACC, 2013

  31. 房颤消融技术新进展:标测与消融技术 房颤冷冻球囊消融技术

  32. 冷冻球囊疗法已成为AF消融的标准手段 2012 HRS 一致声明 “…逐点射频消融能量和冷冻消融球囊如今已是AF导管消融的两种标准消融系统…” Cryoballoon RF: 3.5-mm Calkins H, et al. Heart Rhythm. April 2012;9(4):632-696.

  33. 冷冻球囊疗法 Arctic Front和Achieve 2. 球囊充气,定位 1. 到达目标静脉 ---从心肌细胞中吸热达到消融的目的 --- 从温度骤降开始 ---从接触的位置开始消融 3. 阻塞肺静脉进行冷冻消融 4. 实现PVI

  34. 标准流程--无需复杂的三维标测 冷冻球囊 • 冷冻球囊产生环形的损伤,每个肺静脉隔离2-3次以达到PVI • 冷冻球囊无需三维标测,降低手术的复杂度 • Achieve标测电极通过冷冻球囊的导引钢丝空腔送入,从而最小化术中更换导管的可能 • 整个手术仅需一次房间隔穿刺 Achieve 标测电极 X线透视下,注射造影剂可见左上肺静脉已完全被阻塞 Image: Courtesy of Dr. Vogt, Herz- und Diabeteszentrum NRW, Germany

  35. 实时评估肺静脉隔离-- 应用 Achieve 标测导管 • 在应用Arctic Front冷冻球囊进行冷冻消融时,Achieve标测导管可以实时评估肺静脉隔离情况 Arctic Front冷冻球囊放置在左下肺静脉口,通过Achieve标测导管评估肺静脉隔离情况 延迟 延迟更多 隔离 Images: Courtesy of Dr. Schwagten, ZNA Middelheim, Belgium (above) and Dr. Vogt, Herz- und Diabeteszentrum NRW, Germany (right)

  36. 冷冻球囊消融有效性 Andrade, et al¹: 收集539篇文献 , 23 篇进入最终分析。 有效性证据: – 超过 98% 的急性期成功率 – 12个月的房颤无复发率: 72.83%(经3个月空白期) – 冷冻消融和射频消融相比,阵发性房颤患者术后6个月和12个月的房 颤无复发率无显著差异

  37. 冷冻消融PVI明显优于AADSTOP-AF研究 • CRYO组3%患者出现严重并发症,其中11%为不严重的膈神经麻痹,约98%可在12个月内缓解 随机对比冷冻球囊消融和药物方法治疗阵发性AF 随访1年 , CRYO组的无AF发生 率为 69.9%显著高于药物组( 7.3%) Packer, et al. JACC, 2013, 61(16):1713-1723

  38. 高效性---更短的手术时间和曝光时间 研究方法: 9个成熟的德国中心 ,444 例手术 回顾性研究--随机化采集资料 排除合并严重并发症的患者 Arctic Front操作比逐点法消融导管系统节省33%手术时间,并能减少 24% 的曝光时间

  39. 安全性 冷冻球囊消融安全性 •Arctic Front 消融后左房速发生率低 •Arctic Front 无心脏穿孔报道

  40. 冷冻消融并发症 膈神经麻痹 ---STOP AF :膈神经损伤(包括手术时交叉用药)急性期发生率为11.2%(29/259例);术后1年时仅1.5%(4/259例)。 ---CAP AF (STOP AF’s Continued Access Protocol),显示膈神经损伤显著降低 ---Andradeet al. 对已公布的 Arctic Front相关研究结果(包括STOP AF)进行了综合分析,显示隔神经损伤降到4.8%。 其中15例患 肺静脉狭窄 左房-食管瘘

  41. 房颤消融技术新进展:标测与消融技术 压力导管在房颤导管消融中的临床应用

  42. 导管贴靠力与消融灶 Vivek Y, et al JCE 2010(21) 806-811

  43. FORCE CONTROL A Balancing Act between Efficacy and Safety Excessive Contact Risk of tamponade Risk of esophagus injury Risk of pops Insufficient Contact Lengthy procedure 30% Redo procedures Wide center effectiveness variability Cappato et al, Circulation 2005

  44. 导管贴靠力测量示意图 Nakagawa et al Circ AE. 2008;1:354-362.

  45. AF的导管消融过程中使用实时接触压力技术是安全可行的AF的导管消融过程中使用实时接触压力技术是安全可行的 心包填塞 High contact force (CF) events CF trace versus procedure time for the patient who experienced tamponade. Kuck, et al.Heart Rhythm, 2012, 9(1):18-23 TOCCATA研究入选阵发性AF 34例。导管与组织接触的压力范围为12 ±10 g至 39 ±29 g ,左房消融的1458次,其中27例(79%) 曾出现短暂接触压力>100 g,1例出现心包填塞

  46. 导管CF是AF消融成功重要决定因素 Reddy, et al. Heart Rhythm, 2012, 9(11):1789-1795 Reddy等[6]进一步分析了TOCCATA研究消融随访结果,平均随访12个月。肺静脉消融平均CF为17.2±13.5 g。平均CF小于10g的患者(5/5例)均AF复发,而平均CF大于20g的患者(8/10例)仅有20% AF复发 结论表明AF消融导管平均接触压力应大于20g

  47. SENSORS monitor the transmitter coils location signal and records the micro-movements of the spring. PRECISION SPRING allows small amount of electrode deflection. TRANSMITTER coil in the tip sends location reference signal about the Spring.

  48. SmartTouch消融导管

  49. SmartTouch消融导管 Haldar, et al. Int J Cardiol, 2012 Haldar等使用3.5 mm的 SmartTouch消融导管完成AF标测和消融过程 共入选了40例AF患者,按1:1比例随机分到盲组和非盲组,每组均有13例 (65%)持续AF患者,其中非盲组的术者能够观察AF消融过程中导管与心房壁接触压力的实时变化;而在盲组中,尽管消融过程记录了导管与心房壁接触压力的实时变化,但术者不了解接触压力的数据

  50. 盲组肺静脉的电传导恢复发生率高 Haldar, et al. Int J Cardiol, 2012 非盲组3例 (3/20,15%)患者中的3个(3/80,4%) 肺静脉的电传导急性恢复;而盲组的14例(14/20,70%)患者中的17个(17/80,21%)肺静脉电传导恢复,盲组发生率显著高于非盲组( p=0.001)

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